Over the last 2 weeks, how often have you been bothered by any of the following problems?

First Name

Last Name

DOB (dd/mm/yyyy)

Post Code

1. Feeling nervous, anxious or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it is hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid as if something awful might happen


Please check you have answered EVERY question. Thank you.